NUR 413: Nursing Concepts For Complex Care Exam
1 With Complete Solutions
When an electrical signal in the heart is aimed directly at the positive electrode, the
deflection seen on the 12-lead ECG or rhythm strip will be:
A. Equiphasic.
B. Negative.
C. Positive.
D. Invisible. - ANSWER C. Positive.
The nurse is interpreting the rhythm strip of a patient and measures the QRS complex as
being three small boxes in width. The nurse interprets this width as:
A. 0.04 seconds.
B. 0.10 seconds.
C. 0.12 seconds.
D. 0.16 seconds. - ANSWER C. 0.12 seconds.
The nurse is interpreting a patient's cardiac rhythm and notes that the PR interval is
0.16 seconds long. The nurse determines that this PR interval indicates:
A. Slower than normal conduction from the SA node through the AV node.
B. Normal conduction from the SA node through the AV node.
C. Faster than normal conduction from the SA node through the AV node.
D. Abnormally fast depolarization of the atria and ventricles. - ANSWER B. Normal
conduction from the SA node through the AV node.
The patient is complaining of midsternal chest discomfort and nausea. The nurse calls
for a 12-lead ECG and notices that the ST segment is newly elevated in two related
leads. The nurse should:
A. Call the provider because the ST segment may indicate myocardial injury.
,B. Continue to monitor the patient, as the ST segment is non-diagnostic.
C. Monitor the patient for increased signs of GI upset.
D. Assure the patient that the ST elevations are normal and of no concern. - ANSWER A.
Call the provider because the ST segment may indicate myocardial injury.
The nurse is calculating the rate for a regular rhythm. There are 20 small boxes before
each R wave. The rate is:
A. 50 beats/min.
B. 75 beats/min.
C. 85 beats/min.
D. 100 beats/min. - ANSWER B. 75 beats/min.
The nurse is caring for an individual who is admitted for chest pain and shortness of
breath. The patient states, "I can't believe I'm having chest pain. I'm a marathon runner
and in good shape." During the night, the patient develops a sinus bradycardia with a
heart rate of 40 beats/min. The nurse should:
A. Ignore this rate since the patient is an athlete.
B. Assess the patient and assess for signs of decreased cardiac output.
C. Take the patient's temperature and expect to find hyperthermia.
D. Perform carotid massage (a maneuver to stimulate a vasovagal response). - ANSWER
B. Assess the patient and assess for signs of decreased cardiac output.
The patient is admitted with a heart rate of 144 beats/min and a blood pressure of 88/42
mm Hg. The patient complains of generalized weakness and fatigue. He states, "Just let
me sleep." The nurse determines that the presence of the patient's symptoms is due to:
A. Decreased cardiac output.
B. The absence of ischemic heart disease.
C. Improved cardiac filling time allowing the patient to relax.
D. Increased coronary artery filling time. - ANSWER A. Decreased cardiac output.
, If the sinus node were diseased or ischemic and no longer firing as the heart's primary
pacemaker, the nurse would anticipate which normal compensatory mechanism?
A. Premature junctional beats
B. Junctional escape rhythm, rate of 45
C. Junctional tachycardia, rate of 100
D. Accelerated junctional rhythm, rate of 75 - ANSWER B. Junctional escape rhythm,
rate of 45
The patient complains of being "lightheaded," and feeling a "fluttering" in his chest. The
nurse places the patient on the heart monitor and notices an atrial tachycardia at a rate
of 160 beats per minute. The patient's blood pressure has dropped from 128/76 mm Hg
to 92/46 mm Hg but appears stable at the lower pressure. The nurse should:
A. Prepare the patient for asynchronized defibrillation.
B. Give the patient digitalis IV, then call the provider.
C. Call the provider and prepare the patient for medical or electrical cardioversion.
D. Withhold beta-blocker and calcium channel blockers. - ANSWER C. Call the provider
and prepare the patient for medical or electrical cardioversion.
The nurse notices ventricular tachycardia on the heart monitor. The nurse's first action
should be to:
A. Determine patient responsiveness and presence of a pulse.
B. Immediately defibrillate the patient and provide CPR.
C. Administer intravenous amiodarone or lidocaine.
D. Cardiovert electrically into a more sustainable rhythm. - ANSWER A. Determine
patient responsiveness and presence of a pulse.
The nurse is speaking with the patient when the monitor shows that the patient is in
ventricular fibrillation (VF). The nurse should:
A. Immediately defibrillate the patient.
B. Initiate basic life-support protocols and call for help.
C. Assess the patient and check the patient's monitor leads.
1 With Complete Solutions
When an electrical signal in the heart is aimed directly at the positive electrode, the
deflection seen on the 12-lead ECG or rhythm strip will be:
A. Equiphasic.
B. Negative.
C. Positive.
D. Invisible. - ANSWER C. Positive.
The nurse is interpreting the rhythm strip of a patient and measures the QRS complex as
being three small boxes in width. The nurse interprets this width as:
A. 0.04 seconds.
B. 0.10 seconds.
C. 0.12 seconds.
D. 0.16 seconds. - ANSWER C. 0.12 seconds.
The nurse is interpreting a patient's cardiac rhythm and notes that the PR interval is
0.16 seconds long. The nurse determines that this PR interval indicates:
A. Slower than normal conduction from the SA node through the AV node.
B. Normal conduction from the SA node through the AV node.
C. Faster than normal conduction from the SA node through the AV node.
D. Abnormally fast depolarization of the atria and ventricles. - ANSWER B. Normal
conduction from the SA node through the AV node.
The patient is complaining of midsternal chest discomfort and nausea. The nurse calls
for a 12-lead ECG and notices that the ST segment is newly elevated in two related
leads. The nurse should:
A. Call the provider because the ST segment may indicate myocardial injury.
,B. Continue to monitor the patient, as the ST segment is non-diagnostic.
C. Monitor the patient for increased signs of GI upset.
D. Assure the patient that the ST elevations are normal and of no concern. - ANSWER A.
Call the provider because the ST segment may indicate myocardial injury.
The nurse is calculating the rate for a regular rhythm. There are 20 small boxes before
each R wave. The rate is:
A. 50 beats/min.
B. 75 beats/min.
C. 85 beats/min.
D. 100 beats/min. - ANSWER B. 75 beats/min.
The nurse is caring for an individual who is admitted for chest pain and shortness of
breath. The patient states, "I can't believe I'm having chest pain. I'm a marathon runner
and in good shape." During the night, the patient develops a sinus bradycardia with a
heart rate of 40 beats/min. The nurse should:
A. Ignore this rate since the patient is an athlete.
B. Assess the patient and assess for signs of decreased cardiac output.
C. Take the patient's temperature and expect to find hyperthermia.
D. Perform carotid massage (a maneuver to stimulate a vasovagal response). - ANSWER
B. Assess the patient and assess for signs of decreased cardiac output.
The patient is admitted with a heart rate of 144 beats/min and a blood pressure of 88/42
mm Hg. The patient complains of generalized weakness and fatigue. He states, "Just let
me sleep." The nurse determines that the presence of the patient's symptoms is due to:
A. Decreased cardiac output.
B. The absence of ischemic heart disease.
C. Improved cardiac filling time allowing the patient to relax.
D. Increased coronary artery filling time. - ANSWER A. Decreased cardiac output.
, If the sinus node were diseased or ischemic and no longer firing as the heart's primary
pacemaker, the nurse would anticipate which normal compensatory mechanism?
A. Premature junctional beats
B. Junctional escape rhythm, rate of 45
C. Junctional tachycardia, rate of 100
D. Accelerated junctional rhythm, rate of 75 - ANSWER B. Junctional escape rhythm,
rate of 45
The patient complains of being "lightheaded," and feeling a "fluttering" in his chest. The
nurse places the patient on the heart monitor and notices an atrial tachycardia at a rate
of 160 beats per minute. The patient's blood pressure has dropped from 128/76 mm Hg
to 92/46 mm Hg but appears stable at the lower pressure. The nurse should:
A. Prepare the patient for asynchronized defibrillation.
B. Give the patient digitalis IV, then call the provider.
C. Call the provider and prepare the patient for medical or electrical cardioversion.
D. Withhold beta-blocker and calcium channel blockers. - ANSWER C. Call the provider
and prepare the patient for medical or electrical cardioversion.
The nurse notices ventricular tachycardia on the heart monitor. The nurse's first action
should be to:
A. Determine patient responsiveness and presence of a pulse.
B. Immediately defibrillate the patient and provide CPR.
C. Administer intravenous amiodarone or lidocaine.
D. Cardiovert electrically into a more sustainable rhythm. - ANSWER A. Determine
patient responsiveness and presence of a pulse.
The nurse is speaking with the patient when the monitor shows that the patient is in
ventricular fibrillation (VF). The nurse should:
A. Immediately defibrillate the patient.
B. Initiate basic life-support protocols and call for help.
C. Assess the patient and check the patient's monitor leads.
